- Email: [email protected]
Quality of life of living donors before and after living donor liver transplantation
DONORS
Quality of Life of Living Donors Before and After Living Donor Liver Transplantation M. Walter, G. Dammann, C. Papachristou, A. Pascher, P. Neuhaus, G. Danzer, and B.F. Klapp ABSTRACT Living donor liver transplantation (LDLT) is becoming an established method for treatment of terminal liver disease in adults. After resection of the right hepatic lobe, postoperative complications can arise in healthy donors, and even individual cases of death have been recorded. There remains, however, little research on the psychosocial aspects in living donors before and after LDLT. Using the WHOQOL questionnaire, this prospective study investigates the quality of life (QoL) in a sample of 28 living donors, including the relationship between postoperative complications and QoL before and 6 months after donation. Before LDLT, the donor QoL is high, above that of the general healthy population. After LDLT, a significant reduction in the QoL appears in the areas of “physical health” and “living conditions.” Nevertheless, the QoL remains above the level of the general population. Only two donors showed general QoL values below those of the general population. The postoperative complications had no significant influence on the QoL after transplantation. The high QoL of donors following LDLT indicates a positive psychosocial outcome for the majority of donors, irrespective of donation-related complications. Additional psychosocial studies will be necessary to disclose predictors for an unfavorable psychosocial outcome following LDLT.
A
DULT RIGHT HEPATIC living donor liver transplantation (LDLT) has gained widespread acceptance as an effective procedure for patients with terminal liver diseases. The disadvantage of LDLT is the risk of complications or death in an healthy donor.1 Furthermore, there is little research available on the psychosocial outcome of donors after LDLT.2,3 The present study looks into changes of donor-related quality of life (QoL) and the relationships between postoperative complications and QoL in the first half year following LDLT. PATIENTS AND METHODS Donors From August 2000 to January 2002, 30 living donor liver transplantations were performed at the Charite´ in Berlin. The sample
consisted of 16 women (53.3%) and 14 men (46.6%); the average age was 41 years old. In 27 donors, resection of the right hepatic lobe was performed, and in three others, the left lateral liver segment was resected. Both before and 6 months after LDLT our outpatient psychosomatics unit conducted evaluative interviews and psychological tests with the donors. Two donors were excluded from the
From the Psychiatric University Clinic (M.W., G.D.), Basel, Switzerland, and Clinic for Abdominal and General Surgery (A.P., P.N.) and Clinic for Internal Medicine—Psychosomatics (M.W., C.P., G.D.), Charite´, Campus Mitte, Humboldt-University, Berlin, Germany. Address reprint requests to Marc Walter, Psychiatric University Clinic, Willhelm Klein-Strasse 27, CH-4025 Basel, Switzerland. E-mail: [email protected]
© 2003 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/03/$–see front matter doi:10.1016/j.transproceed.2003.10.048
Transplantation Proceedings, 35, 2961⫺2963 (2003)
2961
2962
WALTER, DAMMANN, PAPACHRISTOU ET AL
Fig 1.
QoL before and after LDLT.
psychometric evaluation due to lack of adequate knowledge of the German language. The sample thus consisted of 28 donors.
tected after the operation. One donor was found to have symptoms of Me´nie`re’s disease.
Psychometric Instrument
QoL Before and After LDLT
QoL is defined as an individual’s perception of his or her position in life in the context of culture and value systems. As a measure of QoL, we used the WHOQOL-BREF Questionnaire, covering the domains physical health, psychological state, social functioning, and living conditions and a global assessment of QoL.4 The questionnaire showed high validity and reliability. Donor data were compared with norms for the German population.5 Statistical analyses were performed with SPSS/11.0 for Windows. We used the t test for dependent samples for comparisons across time and the t test for independent samples for group comparisons. The level of significance was set at P ⬍ .05.
Before LDLT, donors scored their quality of life in all QoL domains better than the general population (P ⬍ .05). Six months after LDLT, they rated the domains “physical health” (t ⫽ ⫺2.44, df ⫽ 27, P ⬍ .05) and “living conditions” (t ⫽ ⫺2.55, df ⫽ 27, P ⬍ .05) significantly lower than before surgery. The QoL scores remained, however, higher than those of the normal population (Fig 1). After LDLT, two donors (7.1%) showed lower values for the global QoL, while 26 donors (92.9%) demonstrated values higher than the normal population.
RESULTS Social Data Before LDLT
Correlations Between Postoperative Complications and Postoperative QoL
All 28 donors were living in a stable partnership. Twenty-three were married (82.1%), three unmarried (10.7%), and two divorced (7.1%). Nineteen donors were employed (67.8%), nine (32.1%) were not. The donors were the spouses (n ⫽ 10, 35.7%), the children (n ⫽ 7, 25.0%), the parents (n ⫽ 6, 21.4%), the brothers (n ⫽ 3, 10.7%), a sister in-law (n ⫽ 1, 3.5%) and an aunt (n ⫽ 1, 3.5%) of the recipients.
In their postoperative QoL, the donors (n ⫽ 5) who were affected by postoperative complications did not differ significantly from the other donors (global Qol: Z ⫽ ⫺0.66, P ⫽ .60).
Complications Following LDLT
Donor lethality was 0%. Five donors (17.9%) were affected by postoperative complications. Two cases of bile leakage were conservatively cured with the aid of stent insertion; one of these cases involved a sympathetic pleural effusion. One donor underwent surgical revision because of diffuse postoperative hemorrhaging in connection with heparin overdose. In another, a benign papillary stenosis was de-
DISCUSSION
The present post-LDLT follow-up study found a very good QoL in living donors before and after transplantation. As evidenced by their WHOQOL scores, they report a better QoL than the normal population. These findings have been noted in QoL studies of recipients after liver transplantation6 and of donors after kidney transplantation.7 Only two donors did not show this high level of QoL following liver transplantation. Donors with low QoL also showed higher scores for psychosocial stress and anxious depression following the operation.8 We therefore conclude
QUALITY OF LIFE OF LIVING DONORS
that about 10% of the donors showed difficulty coping strategy with psychological symptoms, while 90% have very good psychosocial outcomes after donation. Until today, it has been unclear what factors are responsible for unfavorable coping strategies. Postoperative complications likewise did not have significant influence on postoperatively measured QoL. This finding confirms our prior results, proving that complications in donors were neither associated with postoperative mood nor with experiencing psychosocial stress.2,8 Moreover, in QoL studies in liver transplant recipients no significant correlation between complications and QoL could be proven.9 Whereas difficulty in coping following living donor liver transplantation in a few donors could be traced to psychosocial variables, the majority of donors show positive outcomes following living donation with high QoL scores lying even above the normal population. REFERENCES 1. Broelsch CE, Malago ´ M, Testa G, et al: Living donor liver transplantation in adults: outcome in Europe. Liver Transplantation 6:S64, 2000
2963 2. Walter M, Bronner E, Pascher A, et al: Psychosocial outcome of living donors after living donor liver transplantation. Clinical Transplantation 16:339, 2002 3. Trotter JF, Talamantes M, McClure M, et al: Right hepatic lobe donation for living donor liver transplantation: impact on donor quality of life. Liver Transplantation 7:485, 2001 4. The WHOQOL Group: Development of the World Health Organisation WHOQOL— brief quality of life assessement. Psychological Medicine 28:551, 1998 5. Angermeyer MC, Kilian R, Matschinger H: WHOQOL-100 und WHOQOL-Bref Handbuch fu ¨r die deutsche Version der WHO Instrumente zur Erfassung von Lebensqualita¨t. Go ¨ttigen: Hogrefe; 2000 6. Walter M, Moyzes D, Rose M, et al: Psychosomatic interrelations following liver transplantation. Clinical Transplantation 16:301, 2002 7. Johnson EM, Anderson JK, Jacobs C, et al: Long-term follow-up of living kidney donors: quality of life after donation. Transplantation 67:717, 1999 8. Walter M, Papachristou C, Fliege H, et al: Psychosocial stress of living donors after living donor liver transplantation. Transplant Proc 34:3291, 2002 9. Hunt CM, Camargo CA, Dominitz JA, et al: Effect of postoperative complications on health and employment following liver transplantation. Clinical Transplantation 12:99, 1998
Quality of Life of Living Donors Before and After Living Donor Liver Transplantation M. Walter, G. Dammann, C. Papachristou, A. Pascher, P. Neuhaus, G. Danzer, and B.F. Klapp ABSTRACT Living donor liver transplantation (LDLT) is becoming an established method for treatment of terminal liver disease in adults. After resection of the right hepatic lobe, postoperative complications can arise in healthy donors, and even individual cases of death have been recorded. There remains, however, little research on the psychosocial aspects in living donors before and after LDLT. Using the WHOQOL questionnaire, this prospective study investigates the quality of life (QoL) in a sample of 28 living donors, including the relationship between postoperative complications and QoL before and 6 months after donation. Before LDLT, the donor QoL is high, above that of the general healthy population. After LDLT, a significant reduction in the QoL appears in the areas of “physical health” and “living conditions.” Nevertheless, the QoL remains above the level of the general population. Only two donors showed general QoL values below those of the general population. The postoperative complications had no significant influence on the QoL after transplantation. The high QoL of donors following LDLT indicates a positive psychosocial outcome for the majority of donors, irrespective of donation-related complications. Additional psychosocial studies will be necessary to disclose predictors for an unfavorable psychosocial outcome following LDLT.
A
DULT RIGHT HEPATIC living donor liver transplantation (LDLT) has gained widespread acceptance as an effective procedure for patients with terminal liver diseases. The disadvantage of LDLT is the risk of complications or death in an healthy donor.1 Furthermore, there is little research available on the psychosocial outcome of donors after LDLT.2,3 The present study looks into changes of donor-related quality of life (QoL) and the relationships between postoperative complications and QoL in the first half year following LDLT. PATIENTS AND METHODS Donors From August 2000 to January 2002, 30 living donor liver transplantations were performed at the Charite´ in Berlin. The sample
consisted of 16 women (53.3%) and 14 men (46.6%); the average age was 41 years old. In 27 donors, resection of the right hepatic lobe was performed, and in three others, the left lateral liver segment was resected. Both before and 6 months after LDLT our outpatient psychosomatics unit conducted evaluative interviews and psychological tests with the donors. Two donors were excluded from the
From the Psychiatric University Clinic (M.W., G.D.), Basel, Switzerland, and Clinic for Abdominal and General Surgery (A.P., P.N.) and Clinic for Internal Medicine—Psychosomatics (M.W., C.P., G.D.), Charite´, Campus Mitte, Humboldt-University, Berlin, Germany. Address reprint requests to Marc Walter, Psychiatric University Clinic, Willhelm Klein-Strasse 27, CH-4025 Basel, Switzerland. E-mail: [email protected]
© 2003 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/03/$–see front matter doi:10.1016/j.transproceed.2003.10.048
Transplantation Proceedings, 35, 2961⫺2963 (2003)
2961
2962
WALTER, DAMMANN, PAPACHRISTOU ET AL
Fig 1.
QoL before and after LDLT.
psychometric evaluation due to lack of adequate knowledge of the German language. The sample thus consisted of 28 donors.
tected after the operation. One donor was found to have symptoms of Me´nie`re’s disease.
Psychometric Instrument
QoL Before and After LDLT
QoL is defined as an individual’s perception of his or her position in life in the context of culture and value systems. As a measure of QoL, we used the WHOQOL-BREF Questionnaire, covering the domains physical health, psychological state, social functioning, and living conditions and a global assessment of QoL.4 The questionnaire showed high validity and reliability. Donor data were compared with norms for the German population.5 Statistical analyses were performed with SPSS/11.0 for Windows. We used the t test for dependent samples for comparisons across time and the t test for independent samples for group comparisons. The level of significance was set at P ⬍ .05.
Before LDLT, donors scored their quality of life in all QoL domains better than the general population (P ⬍ .05). Six months after LDLT, they rated the domains “physical health” (t ⫽ ⫺2.44, df ⫽ 27, P ⬍ .05) and “living conditions” (t ⫽ ⫺2.55, df ⫽ 27, P ⬍ .05) significantly lower than before surgery. The QoL scores remained, however, higher than those of the normal population (Fig 1). After LDLT, two donors (7.1%) showed lower values for the global QoL, while 26 donors (92.9%) demonstrated values higher than the normal population.
RESULTS Social Data Before LDLT
Correlations Between Postoperative Complications and Postoperative QoL
All 28 donors were living in a stable partnership. Twenty-three were married (82.1%), three unmarried (10.7%), and two divorced (7.1%). Nineteen donors were employed (67.8%), nine (32.1%) were not. The donors were the spouses (n ⫽ 10, 35.7%), the children (n ⫽ 7, 25.0%), the parents (n ⫽ 6, 21.4%), the brothers (n ⫽ 3, 10.7%), a sister in-law (n ⫽ 1, 3.5%) and an aunt (n ⫽ 1, 3.5%) of the recipients.
In their postoperative QoL, the donors (n ⫽ 5) who were affected by postoperative complications did not differ significantly from the other donors (global Qol: Z ⫽ ⫺0.66, P ⫽ .60).
Complications Following LDLT
Donor lethality was 0%. Five donors (17.9%) were affected by postoperative complications. Two cases of bile leakage were conservatively cured with the aid of stent insertion; one of these cases involved a sympathetic pleural effusion. One donor underwent surgical revision because of diffuse postoperative hemorrhaging in connection with heparin overdose. In another, a benign papillary stenosis was de-
DISCUSSION
The present post-LDLT follow-up study found a very good QoL in living donors before and after transplantation. As evidenced by their WHOQOL scores, they report a better QoL than the normal population. These findings have been noted in QoL studies of recipients after liver transplantation6 and of donors after kidney transplantation.7 Only two donors did not show this high level of QoL following liver transplantation. Donors with low QoL also showed higher scores for psychosocial stress and anxious depression following the operation.8 We therefore conclude
QUALITY OF LIFE OF LIVING DONORS
that about 10% of the donors showed difficulty coping strategy with psychological symptoms, while 90% have very good psychosocial outcomes after donation. Until today, it has been unclear what factors are responsible for unfavorable coping strategies. Postoperative complications likewise did not have significant influence on postoperatively measured QoL. This finding confirms our prior results, proving that complications in donors were neither associated with postoperative mood nor with experiencing psychosocial stress.2,8 Moreover, in QoL studies in liver transplant recipients no significant correlation between complications and QoL could be proven.9 Whereas difficulty in coping following living donor liver transplantation in a few donors could be traced to psychosocial variables, the majority of donors show positive outcomes following living donation with high QoL scores lying even above the normal population. REFERENCES 1. Broelsch CE, Malago ´ M, Testa G, et al: Living donor liver transplantation in adults: outcome in Europe. Liver Transplantation 6:S64, 2000
2963 2. Walter M, Bronner E, Pascher A, et al: Psychosocial outcome of living donors after living donor liver transplantation. Clinical Transplantation 16:339, 2002 3. Trotter JF, Talamantes M, McClure M, et al: Right hepatic lobe donation for living donor liver transplantation: impact on donor quality of life. Liver Transplantation 7:485, 2001 4. The WHOQOL Group: Development of the World Health Organisation WHOQOL— brief quality of life assessement. Psychological Medicine 28:551, 1998 5. Angermeyer MC, Kilian R, Matschinger H: WHOQOL-100 und WHOQOL-Bref Handbuch fu ¨r die deutsche Version der WHO Instrumente zur Erfassung von Lebensqualita¨t. Go ¨ttigen: Hogrefe; 2000 6. Walter M, Moyzes D, Rose M, et al: Psychosomatic interrelations following liver transplantation. Clinical Transplantation 16:301, 2002 7. Johnson EM, Anderson JK, Jacobs C, et al: Long-term follow-up of living kidney donors: quality of life after donation. Transplantation 67:717, 1999 8. Walter M, Papachristou C, Fliege H, et al: Psychosocial stress of living donors after living donor liver transplantation. Transplant Proc 34:3291, 2002 9. Hunt CM, Camargo CA, Dominitz JA, et al: Effect of postoperative complications on health and employment following liver transplantation. Clinical Transplantation 12:99, 1998